Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review

Background
The incidence and mortality from necrotizing fasciitis (NF) are increasing in New Zealand (NZ). Triggered by a media report that traditional Samoan tattooing was causing NF, we conducted a chart review to investigate the role of this and other predisposing and precipitating factors and to document NF microbiology, complications and interventions in NZ.

Methods
We conducted a retrospective review of 299 hospital charts of patients discharged with NF diagnosis codes in eight hospitals in NZ between 2000 and 2006. We documented and compared by ethnicity the prevalence of predisposing and precipitating conditions, bacteria isolated, complications and interventions used.

Results
Out of 299 charts, 247 fulfilled the case definition. NF was most common in elderly males. Diabetes was the most frequent co-morbid condition, followed by obesity. Nearly a quarter of patients were taking non-steroidal anti-inflammatory drugs (NSAID). Traditional Samoan tattooing was an uncommon cause. Streptococcus pyogenes and Staphylococcus aureus were the two commonly isolated bacteria. Methicillin-resistant Staphylococcus aureus was implicated in a relatively small number of cases. Shock, renal failure, coagulation abnormality and multi-organ dysfunction were common complications. More than 90% of patients underwent surgical debridement, 56% were admitted to an intensive care unit (ICU) and slightly less than half of all patients had blood product transfusion. One in six NF cases had amputations and 23.5% died.

Conclusion
This chart review found that the highest proportion of NF cases was elderly males with co-morbidities, particularly diabetes and obesity. Tattooing was an uncommon precipitating event. The role of NSAID needs further exploration. NF is a serious disease with severe complications, high case fatality and considerable use of health care resources.

Aspects of the production of viscous capsular material by the yoghurt starter, streptococcus thermophilus

The technology of modern fermented milk production is not complicated and relies largely on the characteristics of the microorganisms used in its manufacture. Biochemical substances excreted by the starter cultures contribute to the chemical, physical and organoleptic properties of cultured milks. Chemical and organoleptic properties of yoghurt starter cultures have been widely studied over several decades. Conversely the biosynthetic processes and genetic control of the production of viscous extracellular material (slime) by selected thermophillic streptococci is still insufficiently understood. This study attempted to elucidate physiological aspects and the genetic control of slime production. An attempt to chemically induce ropiness was also preformed. Twenty strains of Gram positive, thermo-tolerant, milk dotting, catalase negative cocci were collected from a variety of sources. All strains were identified as Streptococcus thermophilus. Four of the isolates were identified as capable of producing an extracellular, ‘ropy’ capsular material. A negative staining method for highlighting capsular material under light microscopy was described. Ropy isolates displayed thick capsular zones of between 6-8 μm. The isolates graded as non-ropy produced only small capsular zones (less than 2 μm); two variants displayed no capsular material. Instability of the ropy phenotype during subculture and prolonged storage was described for all four ropy isolates at varied temperatures. Instability during transfer was reported as moderate with a loss of no more than 45% of ropy colonies after 15 subcultures at 48°C A significant increase in instability, during transfer, associated with an increase in incubation temperature (37-48°C) was also reported. Prolonged storage of ropy variants over ten days resulted in a drop in the number of ropy colonies. The loss was minimal when cultures were stored at 8°C, but excessive (approaching 100%) at 37°C This suggested the presence of capsular degradative substances. Analysis of the plasmid profiles of 20 strains identified only two strains harboured plasmid DNA. All plasmids were small, less than 23kilobases, and each strain possessed a single plasmid species. Only one ropy strain contained plasmid DNA that was shown, with the aid of curing experiments, not to be linked to production of the ropy phenotype. The amino acid analogue p-fluoro-DL-phenylalanine was unsuccessful in generating ropy colonies from non-ropy variants of Streptococcus thermophilus at low concentrations. Some technological considerations for the use of ropy variants of Streptococcus thermophilus in yoghurt starter cultures were made.

Antibiotic resistance in invasive Streptococcus pneumoniae isolates identified in Scotland between 1999 and 2007

Data from 4727 invasive isolates of Streptococcus pneumoniae submitted to the Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory between 1999 and 2007 were analysed to establish susceptibility profiles to penicillin, erythromycin and cefotaxime. Pneumococcal resistance to penicillin over the study period remained low, with only 0.2 % (n=7/4727) of isolates falling into this category (MIC ≥2 mg l−1). These isolates have been sporadic, and have mainly represented serogroup 14 (ST9) and 9 (ST156). In comparison, the ‘intermediate sensitivity’ group (MIC 0.12–1 mg l−1) ranged between 2 and 6 % per year, the majority from serogroup 9 (ST156). Over the study period, we found that 12 % (n=585/4727) of isolates were erythromycin-resistant (MIC >0.5 mg l−1), with the majority (n=467; 80 %) of these isolates identified as serogroup 14 (ST9). Cephalosporin resistance (cefotaxime MIC >1 mg l−1) was found in only 0.06 % (n=2/3135) of isolates. Internationally recognized clones (Pneumococcal Molecular Epidemiology Network) accounted for 35 % (n=28/81) of the penicillin non-susceptible isolates and 75 % (n=248/330) of the macrolide-resistant isolates, with ST9 and ST306 predominating. Between 1999 and 2007 we found that 11.6 % (n=18/155) of the penicillin non-susceptible isolates and 4.8 % (n=28/585) of the macrolide-resistant isolates were from serogroups not covered by the 7-valent conjugate pneumococcal vaccine in use in the UK since 2006. Susceptibility to first-line antimicrobial agents for invasive pneumococcal disease in Scotland remained high over the period 1999–2007.

A mathematical model for the spread of streptococcus pneumoniae with transmission due to sequence type

This paper discusses a simple mathematical model to describe the spread of Streptococcus pneumoniae. We suppose that the transmission of the bacterium is determined by multi-locus sequence type. The model includes vaccination and is designed to examine what happens in a vaccinated population if MLSTs can exist as both vaccine and non vaccine serotypes with capsular switching possible from the former to the latter. We start off with a discussion of Streptococcus pneumoniae and a review of previous work. We propose a simple mathematical model with two sequence types and then perform an equilibrium and (global) stability analysis on the model. We show that in general there are only three equilibria, the carriage-free equilibrium and two carriage equilibria. If the effective reproduction number Re is less than or equal to one, then the carriage will die out. If Re > 1, then the carriage will tend to the carriage equilibrium corresponding to the multi-locus sequence type with the largest transmission parameter. In the case where both multi-locus sequence types have the same transmission parameter then there is a line of carriage equilibria. Provided that carriage is initially present then as time progresses the carriage will approach a point on this line. The results generalize to many competing sequence types. Simulations with realistic parameter values confirm the analytical results.

Selection and characterization of probiotic culture of Streptococcus thermophilus from dahi

For the isolation of probiotic cultures of Streptococcus thermophilus from dahi, we collected 120 samples from the southern regions of Punjab, Pakistan. Eleven isolates were obtained, and six were scrutinized for antibacterial activities against food-borne pathogens. The carbohydrate fermentation profile of these six strains was determined by the API50 CHL system. Additionally, these strains were amplified for their 16S rRNA regions to confirm their genotypic relationship. Furthermore, phenotypic characteristics among these strains were established by S-layer protein analysis of their cell walls by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and by plasmid profiling. The outer cell wall layers of these strains have 6-14 different sizes of protein bands of 27, 34, 37, 40, 45 and 60 kDa molecular weight. Similarly, except S02FT, all strains have a single prominent plasmid of 23 kbp, whereas S02FT has an additional plasmid of 9 kbp. On the basis of this unique feature and a wide spectrum of killing patterns against pathogenic bacteria, S. thermophilus S02FT was further characterized. This culture showed an optimum antibacterial activity of 800 AU/ml at pH 5.0-5.5 and a temperature of 30-37°C. It grows well in in vitro acidic conditions and tolerates bile salt up to 2% concentration. It was resistant to nalidixic acid, ciprofloxacin, gentamicin and sulphamethoxazol, but showed intermediate behaviour to vancomycin and erythromycin.